Future Practice Nov 2012 — E-Prescribing

The latest issue of Future Practice features an introduction by CMA President Anna Reid in which she highlights the importance of E-Prescribing. She states, “E-prescribing has long been recognized as a fundamental requirement for the effective use of EMRs by the medical profession. This has been recognized in the United States, where the ability to prescribe electronically forms an important part of the current incentive program to speed EMR adoption. Here at home, on the other hand, an article published in the May 2011 issue of Future Practice noted that ‘asking why Canada does not have widespread electronic prescribing of patient medications can yield a multiplicity of answers, most of them less than satisfactory’.”

E-Prescribing is the last significant foundational component of EMRs that has yet to be integrated. Although most EMRs provide the capability to prescribe medications and perform drug-to-drug interaction checking, prescriptions are generally printed, signed by hand, and handed to the patient. Some EMRs allow prescriptions to be signed using a pen and tablet and faxed directly to the pharmacy. However, the process is essentially unchanged from this point onwards. Prescriptions cannot be transmitted electronically to a central drug repository or directly to a pharmacy. It is not possible for a pharmacy to send a renewal request directly to a physician’s EMR system and it is not possible to prescribe controlled substances.

These are all future functionalities that will progressively be added to EMRs as provincial drug information systems become more widely available. However, it is a big mistake to view E-Prescribing as simply the transmission of a prescription electronically from a prescriber to a pharmacy and then assume that the job is done. Physicians in the United States have been E-Prescribing for the past eight years. Over 50% of physicians now submit prescriptions electronically via their EMR or standalone E-Prescribing systems. More and more is taking place via EMRs as these become more widely adopted. Data is still not complete, as EMRs can generally only query drug payment information from a limited number of pharmacy benefit managers. But once the last pieces are in place, physicians in the U.S. will have one of the most sophisticated electronic drug management systems available anywhere in the world.

I have been talking with a number of EMR vendors about the challenges they face in deploying E-Prescribing in Canada, and I have been talking to U.S. vendors about best practices and lessons learned. There are many nuances, some of which cannot be anticipated until one has faced the challenges and has had to find practical solutions to complex problems.

I will be sharing these observations and lessons learned over the next year as I dig deeper into this complex and crucial area.

Comments

Alan, I think the guys in the trenches are ready to go, it is the provinicial College of Pharmacists that are holding up the works. In Ontario, the Pharmacist will be fined if they accept a document without an "original signature".

Warning! I am a practicing doctor who sees real patients using an electronic medical record (EMR). This is the first line of a blog (http://www.kevinmd.com/blog/2012/12/core-healthcare-renaissance.html) The article went on to talk about various issues related to EMR use and specifically mentioned the McMaster paper that showed a lack of evidence based benefits for computer-based prescribing. Although this conclusion seems to get generalized to EMR use in general. One explanation could be that the systems that were being used were not really what I would call well integrated high performance systems. Most of the data that was looked at was hospital based.

Looking at ePrescribing from a high level perspective does not reveal the difficulties when it gets down to implementation. A physician will do about 10,000 prescriptions per year using about 500 different drugs. There are a few things that have been a headache for many years. It is unfortunate that physician users of these systems are not aware of the difficulties and those that do speak up are ignored. FIRST IS THE UNWARRANTED USE OF ALL CAPITALS FOR DRUG NAMES. Another issue is the fixation of using the full drug name which typically includes the brand name, the strength and the form of the medication. This is not how physicians think of medications. I would like to be able to search for medications by indication, drug class, what the patient has had before and then the name of the drug and after that I would like to see and select the available dosages. Why can't EMRs follow this sequence or at least make it possible for users to search for a drug on these criteria. Another sore point is that if you go to change a dose you generally have to discontinue a prescription and then start a new one having searched for and selected a new drug. Wouldn't it be nicer to let the user just change the strength of the drug? Trying to read and understand the sequence of previously prescribed drugs is usually a miserable exercise because of the way previous prescriptions are recorded. Doing refills of previously used medications can be a pleasure if the EMR has things set up right.

There is continuing pressure for EMRs to use DIN numbers as the identifying code for medications. Staying at a high level I have no hesitation in saying that DIN numbers are the wrong identifier to use because they refer to a specific formulation and package. What is prescribed is not necessarily what is dispensed. There are a number of other choices for identifiers but it should NOT be the DIN number.

While this could be a really attractive function in an EMR the EMR developers have many different and partially functional solutions. Physicians need to recognize the problems, speak up and get the point across that things are just not good enough.